(626) 584-6303
Pasadena, CA
Stephen B. Groton, California Insurance
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Policy Holder
Contact Name
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Date of Birth*
Occupation
Property Location
Address
City
State
Zip Code
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County
Current Homeowner Insurance Information
Company Name
Current Coverage A Dwelling Replacement Value (cost to rebuild)
Expiration Date
Insurance Information
Deductible Desired: It is a percentage of your coverage amount.
10%
15%
20%
25%
Dwelling Information
Is this home owner occupied or a rental?
Owner Occupied
Rental
Estimated Replacement Cost (Coverage A on your home policy)
Square Footage
Year Constructed
Is Your Home over 20 Years Old? If so, What Updates Have Been Made?
Age of Hot Water Heater?
Roof Type and Age?
How Many Floors (Stories)?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other
Type of Construction
Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other
Foundation
(check all that apply)
Slab
Raised - Crawlspace
Basement
Mixed
Bolted to the Foundation
Located within 5 miles of Fire Station
Located 1000 feet from Fire Hydrant
Swimming Pool
Trampoline
Home Located within City Limits
Claims
Any existing damage to your house?
Personal Property
Estimated value of your personal property:
Jewelry & Watches
Furs
Silver
Firearms
Stamp and Coin Collections
Fine Arts and Breakable Items
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